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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209.)468-3420 P 0 BOX 2009, STOCKTON,' CA 95201 i PERM T EXPIRES 1 YE FR M DATE S (Complete in Triplicate) - _ f Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made is compliance with San Joaquin County rdinance Ho. 54,9 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. Z City Lot Size/Acreage Job Address- " ZZ r r /� Address �] Phone Owner's Name 1 + License No.�� - - - Phone / a Contractor ddress NE WELL ❑` WELL REPLACEMENT'Fl DESTRUCTIO t of Service Well !rl TYPE OF WELLlPUMP: 0TH R ❑ monitoring well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC 7ANKI SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, Dia of Well Casing w Cf Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications I-1 Dorneatic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing_ tC1 Other ` ' n Delta Depth of Grout Seal Type of Grout 1'1 Public - i I I Irrigation Approx. Depth I I Eastern Surface Seryl Installed by I H.P. State Work Done Repair Work Done L7 Type of Pump - z o j � L f� i Sealing Material 4 Depth d f n WaN Destruction Wall Diameter ` Piller Material i Depth Ile Al I Depth _ --- - TYPE Of SEPTIC WORK: NEW INSTALLATION l l._,-REPAIR/ADDITION I I DESTRUCTION I l availablerwithin 200 feet{lad rf4 pi sower �f installation will serve: Residence Commercial }Other-- y �C ' Number of fiving units: ' Number of bedrooms j Character of soil to a,depth of 3 feet- - — - -- Water table depth �- No. Compartments SEPTIC TANK. O Type/Mfg, Capacity `� f , Method of Disposal g PKG. TREATMENT PLT. ❑ - . Distance to nearest: Well Foundation. - Property Line'' LEACHING LINE ❑•. No. *.Length of lines'{ 4� 7otal fengthlsize 1� ._ ", i FILTER BED a .;. ❑.Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth s Size Number SUMPS �;�Ll Distance to nearest: Well. - Foundstion Property Line 1 #+ DISPOSAL'PONDS ',;�- ❑ and-that-the work wjll be done in accordance with San Joaquin county ordinances, state taws. and I..hsrelay certify that I have prepared this application t rules and regulations of the San Joaquin County Hoare owner or licensed agent's signature oertifiss the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies"the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." - Wu The applicant s r rsquir ions. Complete drawing on raver Y side. Date, Signed ills: r FOR DEPARTMENT USE ON ti' ti Date `' .F (J !� Area pplication Accepted by { T11- 'W� 'Date �` Final lnspLekdon�by n Data a f� j Pit or Grout Inspsctlon-by Additional Comments: t� e Applicant - Return all copies to: San Joaquin'Cntiinty Public Health Services ' Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ? FEE "" AMOI7NT REAA11TED s CK - RECEIVED BY` DATE PERMIT NO. INFO AMOUNT Ot1E CASH � 521 ] 'h - IZ f 82 2•f1 . EN 13-24 IRti EV. tial �J� K./D EH t�•7a 1 �